A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SPO2 is 89-96%. ABG results are: pH 7.31, PaO2 93 mm Hg, PCO2 5O mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse?
Position the client prone and have the respiratory therapist perform postural drainage.
Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing.
Increase oxygen to 70%.
Switch oxygen to a nonrebreather mask.
The Correct Answer is B
A. Prone positioning and postural drainage are typically not appropriate interventions for a client 1 day postoperative following an open thoracotomy, as this could place stress on the incision site and cause discomfort or injury.
B. High-Fowler's position facilitates lung expansion, which can improve ventilation and oxygenation. Encouraging the use of an incentive spirometer and promoting coughing helps clear secretions and expand the lungs, addressing the mild respiratory acidosis indicated by the ABG results (pH 7.31 and PaCO2 50 mm Hg).
C. Increasing oxygen to 70% is not appropriate, as the PaO2 level is within normal limits (93 mm Hg). The client's issue appears to be related more to ventilation (indicated by the elevated PaCO2) rather than oxygenation, so additional oxygen would not address the underlying cause and could lead to oxygen toxicity if used long-term.
D. A nonrebreather mask delivers a high concentration of oxygen, which is not necessary in this case since the client’s PaO2 is already adequate. The primary issue is not a lack of oxygen but rather the retention of CO2, so promoting ventilation and lung expansion through positioning and respiratory exercises is more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["E"]
Explanation
A. Increased pulse rate:
This is a common manifestation of fluid overload. Excess fluid volume can lead to an increase in cardiac output, causing the heart to pump faster and resulting in an increased pulse rate.
B. Decreased blood pressure:
Fluid overload typically leads to increased blood volume, which can initially cause an increase in blood pressure. However, as fluid overload progresses, it can lead to fluid redistribution, venous congestion, and decreased systemic vascular resistance, ultimately resulting in decreased blood pressure.
C. Skeletal muscle weakness:
Skeletal muscle weakness is not a direct manifestation of fluid overload. It is more commonly associated with electrolyte imbalances, such as hypokalemia or hypomagnesemia, which can occur as a consequence of fluid shifts but are not specific to fluid overload itself.
D. Warm and pink skin:
Warm and pink skin is not typically associated with fluid overload. Instead, it is more indicative of adequate tissue perfusion and oxygenation. In fluid overload, skin changes may include edema, cool and clammy skin due to venous congestion, or signs of skin breakdown in areas of pressure.
E. Distended neck veins:
Distended neck veins, specifically jugular venous distention (JVD), are commonly seen in patients with fluid overload, especially if there is right-sided heart failure or increased central venous pressure. JVD is a result of increased venous return to the heart due to fluid accumulation.
Correct Answer is C
Explanation
A. Superficial infections are caused by fungus.
While fungal infections can indeed cause superficial skin infections like tinea (ringworm) or candidiasis, they are not the common factor for the etiology and pathophysiology of folliculitis, furuncles, and carbuncles. These conditions primarily involve bacterial infections of the hair follicles, typically caused by Staphylococcus aureus bacteria.
B. Parasites get underneath the skin.
Parasitic infections can cause various skin conditions, but they are not the common factor for folliculitis, furuncles, and carbuncles. These conditions are specifically related to bacterial infections of the hair follicles rather than parasitic infestations.
C. Hair follicles are infected or inflamed.
This is the correct choice and the common factor for folliculitis, furuncles, and carbuncles. All three conditions involve the infection or inflammation of hair follicles, primarily due to Staphylococcus aureus bacteria. Folliculitis is the inflammation of one or more hair follicles, furuncles are deeper infections involving the hair follicle and surrounding tissue, and carbuncles are clusters of interconnected furuncles with deeper tissue involvement.
D. There is an allergic response to an allergen.
An allergic response to an allergen does not play a role in the etiology and pathophysiology of folliculitis, furuncles, and carbuncles. These conditions are primarily infectious in nature, involving bacterial colonization and subsequent inflammation of the hair follicles rather than an allergic response.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.